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SOAP Note Template

 

Encounter date:  ________________________     

 

Patient Initials: ______ Gender: M/F/Transgender ____  Age: _____ Race: _____ Ethnicity ____

 

 

Reason for Seeking Health Care: ______________________________________________

 

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________

Current perception of Health:         Excellent     Good     Fair  Poor

Past Medical History

Major/Chronic Illnesses____________________________________________________
Trauma/Injury ___________________________________________________________
Hospitalizations __________________________________________________________

 

Past Surgical History___________________________________________________________

Medications: __________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

Family History:  ____________________________________________________________

 

 

Social history: 

Lives: Single family House/Condo/ with stairs: ___________  Marital Status:________  Employment Status: ______ Current/Previous occupation type: _________________

Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________

Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________

Family Composition: Family/Mother/Father/Alone: _____________________________

Health Maintenance

Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____

Exposures:

Immunization HX: 

 

Review of Systems:

General:

HEENT:

Neck:

Lungs:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Activity & Exercise:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP: 

STI Hx: 

 

Physical Exam

 

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt.   ______ BMI (percentile) _____

General:

HEENT:

Neck:

Pulmonary:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Derm:

Psychosocial:

Misc.

 

Significant data/ Contributing:
 

 

 

Plan:

Differential Diagnoses

1.

2.

3.

Principal Diagnoses

1.

2.

Plan 

Diagnosis

Diagnostic Testing:

Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

 

Diagnosis

Diagnostic Testing:

Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

 

 

 

Signature (with appropriate credentials): __________________________________________

 

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

 

Fill out as if you were with a patient.

 

SCIENCE
HEALTH SCIENCE
NURSING
NURSING 1023C

 

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